The original of this article is in the July 2006 Newsletter of the UK's HIV prevention and treatment organisation, the Terrence Higgins Trust.

HIV and Circumcision

A new study from Uganda appears to show women are less
likely to get HIV from circumcised men, reigniting the debate
about whether circumcision should be advocated to reduce
HIV transmission. But is the debate really so clear cut?

For decades male circumcision has
been justified on preventative
health grounds: sexually
transmitted infections (after
World War One), cervical cancer
(from the 50s) and urinary tract
infections (from the 80s). Now
HIV is cited as a justification.

This latest research into women’s
vulnerability to infection(1) joins
work that for the most part has
previously only considered men.
Some show circumcision reduces
the risk, others that it increases it,
while some demonstrate no effect.
Yet how research is carried out
and reported can mislead.

Circumcision polarises opinion,
with few men neutral about it
(and most researchers in this
area are men). When researchers
come from cultures with a strong
consensus around circumcision, how
impartial will their findings be?
Any discussion about the merits of
circumcision as an HIV prevention
strategy is necessarily coloured
by social attitudes towards the
practice. In Europe circumcision
of young males is rare except
on medical or religious grounds;
interestingly, there are few studies
carried out by Europeans concluding
circumcision is a valid HIV
prevention tool. However,
circumcision is still common
in the United States.

Lower HIV prevalence rates in some
parts of Africa appear to be linked
to higher levels of circumcision and
some previous studies looking at
the risk of men getting HIV from
women suggested circumcision
reduced the risk by 50-75%.(2)(3) But
such studies need to be examined
for biases, such as small or skewed
samples or confounding factors
not being taken into account,
such as:

ethnicity or religion – linked
to both circumcision state and
sexual behaviour

sexual practice – including the
common African practice of ‘dry
sex’, heavily implicated in the
spread of HIV(4)

In the recently published Ugandan
study HIV acquisition was recorded
in women with HIV positive
circumcised or uncircumcised male
partners. Circumcision appeared to
reduce HIV transmission to females
by about 30%. However, this was
not statistically significant as the
sample was too small, a fact the
report did not make clear.

The foreskin also carries Langerhans cells
that HIV seeks out to infect (5)

Circumcision may mean lower incidence
of ulcerative STIs, a known risk factor for
HIV infection

The foreskin is thin and liable to minute
tears, facilitating transmission of the virus
both ways.

Research suggesting circumcision
protects against HIV transmission
has not been carried out over a
particularly long time. It may be
that circumcision only delays
infection and cannot prevent it.
Also, very many ‘cut’ men become
HIV positive and some nations that
routinely circumcise such as the
USA and Ethiopia have high rates
of HIV infection.(6) Mathematical
modelling has shown that if
circumcised men increase their
number of partners any protective
effect disappears and HIV incidence
rises. There is also the question
of the effect on sexual behaviour
and condom use if circumcised
men believe they cannot get or
pass on HIV.

One study showed that circumcision
has much less protective value with
higher viral load and showed
circumcision after puberty failed to
protect (this may have indicated that
Muslims in the study, circumcised
very young, exhibited other factors
that explained their lower infection
rate).(7) In addition, the practice
has been shown to have no or only
limited effect in protecting against
STIs, a major co-factor in the
spread of HIV, especially in the
developing world.(8)

Sex between men
The 2001 Gay Men’s Sex Survey(9)
found circumcised men were
slightly more likely to have
contracted HIV than ‘uncut’ men
(6.1% compared to 5%), a small
but statistically significant
difference seen across ages and
ethnic groups. However, these men
were much more likely to have
become infected through the
lining of the anus than through
the penis.

Australian researchers found no
association between circumcision
status and infection through
insertive unprotected anal
intercourse (UAI) - and men who
had become infected without
reporting UAI were also no more
likely to be ‘cut’. This report
concluded that the foreskin is not
the main source of HIV infection
in gay men who become infected
by insertive UAI and that
circumcision is not strongly
protective against HIV infection
in gay men.(10)

Should circumcision be
promoted?If further randomised control trials
eventually demonstrate beyond
reasonable doubt a protective
effect, should health promoters
encourage boys and men to
be circumcised?

The procedure requires hygiene
and anaesthetic, the availability
of which cannot be assumed
in the developing world. In
such conditions, complications
(including permanent injury to
the penis) are not uncommon.
Crucially, it would be unwise
to assume that findings from
the developing world can be
transposed onto populations
in the industrialised world
with better health care and
much lower burdens of STIs.

Yet in countries where access to
HIV treatment is poor or nonexistent,
might anything that
delays or prevents infection be
welcome? Although not culturally
acceptable among many populations,
research in Botswana
suggests that 81% of men would
undergo circumcision if it could
prevent HIV transmission.(11)
In addition, in cultures where
women find negotiating condom
use difficult, circumcision may
save many women and girls
from infection.

Ethical considerationsChildhood circumcision is
controversial as it involves the
removal, without consent, of
a healthy part of the body with
a definite function (to lubricate
and increase sensation during
sex or masturbation, and provide
a protective cover for the glans).
In addition, many see circumcision
as mutilation. Ethical reservations
can be overcome if circumcision
is left until after childhood, when
consent can be obtained. Might a
health promotion consensus may
be possible around the following
principles?

The procedure should not
be carried out on minors
or promoted to adults.

It should be made available on
request to consenting young
adult males before they become
sexually active.

However, if the conclusions of
researchers around circumcision
are applied to other cultures there
may be accusations of health
promotion ‘colonialism’. There is
also a danger of coercion being
used in any State-sponsored procircumcision
drives, as happened
during family planning campaigns
in India and China.

Care should be taken when
evidence is so contradictory or
unreliable. An association has
not been clearly established. More
randomised clinical trials (that
take into account confounding
factors) are needed before
circumcision can be confirmed
as a potential prevention strategy.

Reducing viral load or treating
ulcerative STIs would almost
certainly make more impact on
transmission rates than circumcising.
Circumcision at birth would
take 15-20 years to start to impact
on HIV transmission rates, during
which time other HIV prevention
technologies will hopefully become
available. Until then this is certain:
a condom offers more protection
than circumcision and circumcised
men will still be told they need
condoms to protect themselves
and their partners.

4. ‘Dry sex’ is a common practice in many
African populations of rubbing drying
herbal preparations and other substances
into the vagina to make it drier and tighter,
in order to increase male pleasure. It is
believed to facilitate HIV transmission
through lacerations and inflammation,
increased condom failure and lack of
vaginal secretions to combat infection.

5. However, Langerhans cells are found in
all genital skin tissue. One study found an
excess of such cells in the foreskin, another
found very few. Nevertheless both concluded
the foreskin led to vulnerability to infection
and recommended circumcision.

6. Around 1 million Americans are estimated
to be living with HIV as of 2003, with
prevalence estimated at 0.6%, the second
highest among Western nations after Spain
(0.7%). Glynn M, Rhodes P. Estimated HIV
prevalence in the United States at the
end of 2003. National HIV Prevention
Conference. June 2005, Atlanta. Abstract
T1-B1101.
Ethiopia’s HIV prevalence is estimated to
be 4.4% (www.unaids.org)

11. Kebaabetswe P et al. Male circumcision:
an acceptable strategy for HIV prevention
in Botswana. Sexually Transmitted Infections
79:214-219, 2003. (81% said they would
be circumcised themselves and 89% said
they would circumcise a male child).